FLT CREW OF CL604 EXPERIENCED GROSS NAV ERROR OVER ICELAND WHEN INCORRECT LATITUDE WAS ENTERED AT AN ENRTE WAYPOINT. RADAR CTLR SLOW ON PICKING UP DEV AS THE NEXT WAYPOINT READ AT 20W WAS FROM FLT PLAN; 'IE; 60N 30W.'
Synopsis
FLT CREW OF CL604 EXPERIENCED GROSS NAV ERROR OVER ICELAND WHEN INCORRECT LATITUDE WAS ENTERED AT AN ENRTE WAYPOINT. RADAR CTLR SLOW ON PICKING UP DEV AS THE NEXT WAYPOINT READ AT 20W WAS FROM FLT PLAN; 'IE; 60N 30W.'
Narrative
ON JUN/THU/03 FLT IN CL604 FROM WARSAW; POLAND (EPWA) TO GANDER; NEWFOUNDLAND (CYQX); THE CREW COMMITTED A GROSS NAV ERROR IN REYKJAVIC CTL'S AIRSPACE WHILE IN A RADAR ENVIRONMENT AND IN RADAR CONTACT. THE CLRED RTE SEGMENT THROUGH THAT AIRSPACE WAS FROM 62N20W TO 60N30W TO 57N40W; ETC. AN INCORRECT 62N30W WAYPOINT WAS ACCIDENTALLY ENTERED INTO THE LONG RANGE NAV SYS INSTEAD OF THE CORRECT WAYPOINT AND THAT ERROR WAS NOT DETECTED BY THE CREW DURING LONG RANGE NAV WAYPOINT/RTE CHKING AND VERIFICATION. THE ERROR WAS FINALLY DETECTED WHEN REYKJAVIC ADVISED THAT WE WERE 67 NM OFF COURSE AND THAT A GROSS NAV ERROR WOULD BE FILED. FACTORS THAT CONTRIBUTED TO THE ERROR CHAIN WERE: 1) ELECTRONIC DOWNLOAD (MORE ACCURATE INFO) WAS EXPECTED BUT NEVER RECEIVED. THE LONG RANGE NAV WAYPOINT ENTRY WAS MANUALLY ENTERED BY THE SIC WITH THE ERROR BEING ENTERED AT THAT TIME ON THE GND PRIOR TO TKOF. 2) EARLY DEP PREVENTED A THOROUGH WAYPOINT CHK ON THE GND. 3) DISTRS WERE PRESENT WITH DIFFICULTY IN CONTACTING OCEANIC CLRNC AGENCY AND RECEIVING OCEANIC CLRNC; AND CORRECT AND ADEQUATE CRUISE ALT. THE CREW WAS COMPLETELY AT FAULT SINCE THE ERROR SHOULD HAVE BEEN DISCOVERED DURING OUR CHALLENGE AND RESPONSE LONG RANGE NAV WAYPOINT VERIFICATION PROC AFTER OCEANIC CLRNC WAS RECEIVED. I BELIEVE THAT THIS PROB COULD BE SOLVED AND THE ERROR PREVENTED BY USING A WAYPOINT VERIFICATION PROC WHEREIN EACH PLT PHYSICALLY VIEWS EACH WAYPOINT AS SHOWN ON THE FLT PLAN; THEN AS DISPLAYED ON THE LONG RANGE NAV EQUIP; AND THEN A VERBAL CORRECTNESS AGREEMENT BTWN THE PLTS IS ACKNOWLEDGED. THIS OF COURSE; NECESSITATES BOTH PLTS ACCOMPLISHING THIS VERIFICATION SIMULTANEOUSLY ALTERNATIVELY; A DOUBLE CHALLENGE AND RESPONSE VERIFICATION COULD BE EMPLOYED WHEREIN ONE PLT READS THE WAYPOINTS ALOUD AND THE OTHER PLT VERIFIES THE CORRECTNESS OF WAYPOINTS AS ENTERED INTO THE LONG RANGE NAV EQUIP. THEN; ANOTHER VERBAL VERIFICATION IS ACCOMPLISHED WHEREIN THE PLTS SWITCH ROLES OF READER AND VERIFIER. I ALSO BELIEVE IT IS ESSENTIAL THAT BOTH PLTS LISTEN TO; COPY AND AGREE UPON THE OCEANIC CLRNC. SUPPLEMENTAL INFO FROM ACN 585796: CREW TOO INVOLVED WITH WHOM TO OBTAIN OCEANIC CLRNC FROM AND ALT CAPABILITY OF ACFT. DID NOT CHK ENTERED FLT PLAN CLOSE ENOUGH.
Source: NASA Aviation Safety Reporting System (public domain). Reports are voluntary submissions and are not verified by NASA.